Change background
0421 310 768
clinic@irlenipswich.com.au
EMAIL ME
MAKE A BOOKING
Home
Who we are
Blog
Assessments
Irlen Assessment
Self Tests
Child Self Test
Teen Self Test
Adult Self Test
Headaches Migraines, Eye Strain, Fatigue Self Test
Light Sensitivity Self Test
ADHD Self Test
Autism Self Test
Training Courses
Research
FAQs
Contact Us
Menu
Home
Who we are
Blog
Assessments
Irlen Assessment
Self Tests
Child Self Test
Teen Self Test
Adult Self Test
Headaches Migraines, Eye Strain, Fatigue Self Test
Light Sensitivity Self Test
ADHD Self Test
Autism Self Test
Training Courses
Research
FAQs
Contact Us
Menu
Home
Who we are
Blog
Assessments
Irlen Assessment
Self Tests
Child Self Test
Teen Self Test
Adult Self Test
Headaches Migraines, Eye Strain, Fatigue Self Test
Light Sensitivity Self Test
ADHD Self Test
Autism Self Test
Training Courses
Research
FAQs
Contact Us
Irlen Syndrome Adult Self Test
PERSONAL DETAILS
Name
*
First
Last
Email
*
Phone
READING
While reading do you?
1. Do you unintentionally skip words or lines or lose your place, re-read lines?
Yes
No
2. Do you have to re-read in order to understand?
Yes
No
3. Are you easily distracted?
Yes
No
4. Do you avoid reading whenever possible?
Yes
No
5. Do you experience headaches or fatigue?
Yes
No
EYE STRAIN
When reading
6. Do your eyes hurt, burn, itch, water, become tired, ache?
Yes
No
7. Does it take energy and effort to see the words clearly?
Yes
No
8. On the computer do your eyes hurt, burn, itch, water, become tired, ache?
Yes
No
9. Does it become progressively worse as reading continues?
Yes
No
PRINT RESOLUTION
When reading do words ever:
10. Blur, seem fuzzy or appear less sharp?
Yes
No
11. Move or merge?
Yes
No
12. Double or distort?
Yes
No
13. Get darker or lighter in colour?
Yes
No
14. Have halos or shadows?
Yes
No
LIGHT SENSITIVITY
Do you find:
15. Sunlight too bright and/or sunglasses a necessity?
Yes
No
16. Fluorescent lighting too bright?
Yes
No
17. It uncomfortable to read or work under fluorescent light?
Yes
No
18. It easier to read in dull or dim light?
Yes
No
19. White pages too white, bright or glary?
Yes
No
20. You squint when outside because the light bothers you?
Yes
No
21. You have difficulty adjusting from bright lights to darkness and/or darkness to bright lights?
Yes
No
22. Computer screens / white boards / Smart Boards / electronic device seem bright?
Yes
No
23. Magazine or text book pages seem shiny or glossy, so you adjust the book in order to eliminate glare?
Yes
No
24. Headlights or streetlights bother you, or have halos?
Yes
No
FATIGUE
25. Experience headaches or migraines?
Yes
No
26. Experience discomfort, strain, fatigue, headaches when using computers?
Yes
No
27. Fatigue after work?
Yes
No
DEPTH PERCEPTION
Do you:
28. Hold onto the railing while walking up or down stairs?
Yes
No
29. Have difficulty getting on or off escalators?
Yes
No
30. Bump into objects when walking e.g. table edges or door jams?
Yes
No
31. Veer into people when walking beside them?
Yes
No
32. Ever feel dizzy when walking?
Yes
No
33. See yourself as clumsy?
Yes
No
34. Experience motion sickness?
Yes
No
35. Have trouble catching, hitting or following a ball while watching sport on TV?
Yes
No
36. Have difficulty judging the distance of oncoming traffic?
Yes
No
37. Leave lots of room between your car and the car ahead?
Yes
No
38. Have difficulty making lane changes or are extra cautious?
Yes
No
39. Feel nervous about passing cars on a two lane road?
Yes
No
40. Tailgate or do your passengers tense when you change lanes?
Yes
No
41. Have difficulty parking the car?
Yes
No
Phone
This field is for validation purposes and should be left unchanged.
(make sure you print before you submit)
